Suffering, Autonomy and Dignity in Palliative Care and Medical Assistance in DyingPanelists: Farr Curlin, MD, hospice and palliative care physician with joint appointments in the School of Medicine, including its Trent Center for Bioethics, Humanities & History of Medicine, and in Duke Divinity School, including its Initiative on Theology, Medicine and Culture; Brandy M. Fox, PhD student, Albert Gnaegi Center for Health Care Ethics at Saint Louis University; Caitlin O’Donnell, PhD(c), University of Waterloo, Ontario; and Andrew Stumpf, PhD, Assistant Professor of Philosophy at St. Jerome’s University, Waterloo, Ontario, and doctoral candidate in Theological Ethics at St. Michael’s College, Toronto, Ontario. Moderator: John Yoon, MD, Assistant Professor of Medicine and Assistant Director, Program on Medicine and Religion, University of Chicago

Proponents of euthanasia and physician-assisted suicide sometimes depict a patient suffering intolerably as having only two choices: (1) continue to suffer terribly until an agonizing death arrives, or (2) receive medical assistance in dying (MAID). (1)Mercy and compassion for our fellow human beings, they argue, require us to offer the second option if assistance in dying should be requested. Others have suggested that the dichotomy on which this reasoning rests is a false one. According to them, a third option, namely access to good palliative care, opens up the landscape of choice for suffering persons dramatically. When treatment has begun sufficiently early, palliative care promises to deal effectively with the various aspects of suffering and indignity besetting individuals who have reached the point where they can no longer tolerate their suffering without help. For this reason, some argue that access to good palliative care renders medical assistance in dying unnecessary. Palliative care satisfies the demands of mercy and compassion without requiring health care professionals to act as agents of death. Further, a palliative care approach respects Christian intuitions about the dignity and worth of human life even in the most debilitated condition.

Question 1: The first and preliminary question this panel will explore concerns how well the claims of palliative care have been substantiated: What are the grounds for thinking that palliative care could effectively alleviate the forms of suffering and sense of indignity that drive people to ask for help to die? We will discuss the literature on this subject and attempt to reach an answer that approaches a reasonable degree of certainty.

Question 2: The second question to be considered in the proposed panel session concerns the relationship between autonomy and MAID. Even on the assumption that good palliative care can deal effectively with extreme forms of suffering, there remain considerations of autonomy. For instance, even if high-quality palliative care were generally accessible, would individuals not retain the right to die with what they perceive as dignity, as well as the right to their physicians’ assistance in doing so? Even if their symptoms are relieved, some individuals will prefer to die rather than to live on in a state that they deem undignified. Patient rights to self-determination and to a dignified death seem to support making MAID legal and available for those who want it.

But autonomy cuts in other directions also. Autonomy requires not only the ability to choose from currently available options, but also that morally significant options are made available for choice. The latter concern would seem to support making it possible for patients to opt not only for MAID, but also for palliative care. If MAID is offered in a context in which good palliative care is not yet reliably available, that may reduce patient autonomy by reducing the public motivation to make good palliative care accessible. In this respect, what lessons can we learn from the effects of the implementation of MAID in the Canadian context, and in American states where physician-assisted suicide has been legalized?

Question 3: The third question revisits the relationship between palliative care and MAID in light of key Judeo- Christian concepts. Central to the philosophy of palliative care is the idea that human life retains worth and dignity at every stage, regardless of debility a person may suffer. The biblical vision of human beings as bearers of the image of God can serve as a foundation for the intrinsic value of human life. What are the implications of this vision for human life at the extremities of suffering? How, in particular, does Jesus’s own suffering and death speak to the value of life in every condition? How can palliative care professionals practice in a way that acknowledges the divine valuation of life? In the end, can MAID be reconciled with respect for the divine image in humanity? ​Question 4: Finally, the panel will extend the discussions of these questions to make ethically and/or theologically based recommendations for jurisdictions that have already implemented some form of medical assistance in dying. (2)

​1 The acronym “MAID” refers, in the Canadian context, to both voluntary active euthanasia and physician- assisted suicide, both of which have been legal in Canada since 2016. The present document uses the acronym to cover both of these forms of medically assisted death, whether in the Canadian setting or elsewhere.

2 In 1990, on the basis of reasoning similar to that considered in the first two questions, the World Health Organization urged member countries not to implement access to euthanasia or assisted suicide until having fully explored palliative care options (See the WHO Expert Committee Report on Cancer Pain Relief and Active Supportive Care, Geneva: World Health Organization, 1990). Since that time, various regions, including some American states and countries including the Netherlands, Belgium, and most recently Canada have legalized some form of MAID. Ethical recommendations directed toward such jurisdictions must take account of the altered legal and social situations now operative there.